The opportunity for public services of truly engaged expert citizens

The World Wide Web was invented in 1989 and Google was incorporated as a company nearly a decade later, in 1998. AirBnB started in 2007 and Uber in 2009.

I wonder why there was such a big delay between the web and Google, and then Google and AirBnB, Uber etc., and then a subsequent delay in their reaching a tipping point in terms of awareness and use by the general public?

I ask this because there have been a very wide number of approaches and initiatives for improving public services, not least health and social care, through technology and particularly the web. For example, there have been care comparison sites a-plenty, much talk of open data and suggestions of location-based services to replace off- and online directories. And yet we see relatively little evidence of these approaching a tipping point, let alone being used regularly by local authorities, providers and the general public when it comes to health and social care.

The prompt for these thoughts is this excellent, detailed post at Policy Exchange about the rise of the citizen expert.

In it Beth Simone Noveck (former United States deputy chief technology officer and director of the White House Open Government Initiative) takes as a starting point another area of public policy – citizen engagement – and notes how the obvious opportunity to improve public services and local communities hasn’t been taken in the way it could have been.

Citizen engagement isn’t just the equivalent of technology: it’s clearly bigger than that. Beth makes clear this point by showing how better harnessing the interests and expertise of citizens can help both bridge the democratic divide and make the most of people in contributing to their local communities and society.

The internet is radically decreasing the costs of identifying diverse forms of expertise so that the person who has taken courses on an online learning platform can showcase those credentials with a searchable digital badge. The person who has answered thousands of questions on a question-and-answer website can demonstrate their practical ability and willingness to help. Ratings by other users further attest to the usefulness of their contributions. In short, it is becoming possible to discover what people know and can do in ever more finely tuned ways and match people to opportunities to participate that speak to their talents.

But she also notes the most significant barrier to this: the continued dominance / monopoly of policy- and service-elites in the work that they do:

[There is a] long-held belief, even among reformers, that only professional public servants or credentialed elites possess the requisite abilities to govern in a complex society.

Why? Because it is believed

Citizens are spectators who can express opinions but cognitive incapacity, laziness or simply the complexity of modern society limit participation to asking people what they feel by means of elections, opinion polls, or social media.

The shifting of the cause of the problem of a lack of engagement onto citizens themselves rather than the professionals asking the questions is a familiar refrain. We regularly hear laments about “the usual suspects”, limited response rates or adversarial consultation processes that create more problems than they solve.

But this characterisation of this situation only makes sense for one set of players: it suits both the technocratic elites who dominate public policy and services, and the other well-embedded elites with (vested) interests who can mobilise quickly to respond to consultation/engagement that affect their organisations.

It is, of course, a characterisation that doesn’t really stand up to scrutiny. For example, we know that (proper) co-production in health and social care has a solid evidence base in the difference it makes. But we also know it continues to be at best a nice-to-have rather than a must-have.

Thus we come back to the questions kicking about in my mind at the start of this post: if the ability to do this sort of thing exists (be it citizen engagement or technology), why hasn’t social care and the like made the most of this opportunity?

It’s largely because elites aren’t yet comfortable with distributing leadership and expertise.

One of the ways to overcome this discomfort, then, is to make it valuable and rational for the existing elites to engage in effective citizen engagement by ensuring a ‘good’ group of people are engaged and involved in public service reform in the first place.

Noveck rightly says:

To make all forms of engagement more effective, we need to increase the likelihood that the opportunity to participate will be known to those who need to participate. If a city really wants to improve the chances of crafting a workable plan for bike lanes, it should be able to reach out to urban planners, transportation engineers, cyclists, and cab drivers and offer them ways to participate meaningfully. When a public organisation needs hands on help from techies to build better websites or data crunching from data scientists, it needs to be able to connect.

To do this:

[I]nstitutions [must] begin to leverage such platforms to match the need for expertise to the demand for it and, in the process, increase engagement becoming more effective and more legitimate.

This is appealing. Citizen engagement may not be valued by elites because there hasn’t been adequate effort or ability to engage sufficient citizens to make it worthwhile enough.

As Noveck concludes:

This is about chances for civic participation; to be a member of a local community and to make a contribution based on this… It has everything to do with what it means to be a citizen in a contemporary democracy.

This is why I particularly like this: this isn’t just about technical changes around the edges of public service economies, but the broad meaningful difference it could make.

 

Public services: only a means to living full and active lives

GYA

I’m involved with the Get Yourself Active campaign and recently wrote a blogpost for it, which is reproduced below. There’s also a fantastic post by Anne Beales of Together UK (on small steps and grand plans) and from Leanne Wightman (who is doing a great job of running the whole project) on the opportunity of Get Yourself Active. You can follow Get Yourself Active via @GetYrselfActive

There were some headlines recently about how people were using their Personal Health Budgets. Concerns were raised about whether items like games consoles, a summer house and satnavs were the best use of public money, with the inevitable calls for resources instead to be focused on traditional ways of doing things – beds, staff, medical equipment.

A positive aspect of the debate was it provided an opportunity for people who have Personal Health Budgets and the professionals who support them to explain why they’re so important in meeting their care and support needs. Kevin Shergold, for example, highlighted:

The PHB has given us freedom to live our lives as we choose – in a way that’s sensible and cost effective. Developing a severe disability might seem hopeless, but I want people to know that it’s possible to live a good, full, interesting life when you have the right support and choice.

This gets to what I think is a vital but often unasked question: what is the point of public services and so the money that funds them?

The vast majority of people with lived experience and who have used care and support services say that they want a life, not a service. Their focus isn’t on getting a few more hours of home care here or seeing an occupational therapist there; it’s about living as full and enriching a life as possible.

Norman Kirk – a New Zealand Prime Minister in the 1970s – described it this way:

People don’t want much. They just want someone to love, somewhere to live, somewhere to work and something to hope for.

He could well have added “something to do”, because wanting to be physically active or play sport is often reported by all people, including disabled people, as a key source of general wellbeing.

The point of public services and the money that funds them, therefore, covers being a means to support wellbeing and achieve what people want to do in their lives – including being active and playing sport. We have already heard from a number of people through the Get Yourself Active project that using their personal budget in this way has changed things for the better.

This means there are three main reasons why I feel Get Yourself Active is such an important contribution:

  1.  It helps to support people who use care and support services and the professionals who work in them to recognise the value of physical activity and sport
  2.  It provides a much-needed wider focus on how Personal Budgets can be used to directly support such activity, and not just focus on traditional ways of meeting people’s needs
  3. And, by the way, it helps councils and their partners meet the general wellbeing requirements of the Care Act.

If this leads to more stories about how Personal Budgets are being used to fund exercise classes, gym memberships or being involved sporting activity, I for one won’t be disappointed. It will mean that public services are doing their job well.

 

Social care council tax precept: the beginnings of an opportunity?

social care precept
The distribution of revenue raised for each council per head by the social care precept (Source: Richard Humphries at the King’s Fund)

First, some facts on where we are with local government and social care spending:

  • Local government saw a 37% real-terms cut in government funding between 2010/11 and 2015/16 (NAO (pdf), executive summary)
  • Adult social care expenditure fell by 8.7% in real terms between 2010/11 and 2014/15 (NAO (pdf), para 1.15)
  • There has been a corresponding fall in social care activity in all areas of social care: homecare, day care, nursing care and residential care (between 2008/09 and 2013/14 – when data is available) (NAO (pdf), figure 4)
  • Net local government spending per person (excluding public health, education, police and fire services) has been reduced by 23.4% between 2009/10 to 2014/15 (IFS (pdf), table 2.1)

Second, the effects of the social care precept. (Recall that the council tax precept for social care was introduced in the 2015 Spending Review, and is the ability of local government to raise council tax by up to 2%, as long as it is spent on social care.)

  • LGA analysis suggests the council tax precept for social care would raise £400million in 2016/17, but only if all 152 local authorities used the precept in full
  • The average Band D taxpayer would see an average rise of £24 in their council tax bill if the precept were used in full in 2016/17 (LGA)
  • (The LGA has previously estimated that the social care funding gap would grow by at least £700 million in 2016/17. The introduction of the National Living Wage will cost councils at least £340 million in 2016/17 on top of this gap)
  • Though the Treasury thinks the social care precept will raise £2billion by 2019/20, the King’s Fund notes the precept will (a) widen the gap in provision between richer and poorer areas, and (b) raise at most only £800m a year.

It’s hardly grounds for optimism is it?

And yet, I find myself wondering if there are reasons for hope in the social care precept? I suggest this for two reasons:

  1. By saying that social care costs can be met by a centrally-enabled (general) tax, it feels to me that the government has set a precedent for funding social care through general taxation. This has not been an option government has realistically considered before, though there are plenty of ways general taxes can be levied and used (see, for example, pp.31-37 of the final report of the Barker Commission (pdf))
  2. People will notice if their council tax bills rise. They’ll probably not appreciate it, and will want to know why their bills have gone up by an average of £24 for social care alone. We know that the general public has very little awareness of how social care is funded (see Chapter 2 of Ipsos Mori’s research for the Dilnot Commission (pdf)), so this therefore represents a communications opportunity that could begin to put social care (and how it is funded) on a par with the NHS in terms of public awareness.

It’s not much to go on, but the ability to make the case for adequate and sustainable funding for social care needs all the help it can get. The social care precept itself is neither adequate nor sustainable; but it might be the beginnings of an opportunity.

Culture change is change if we understand culture properly

Change cartoon

I enjoyed Alex’s post on why “culture change is no change”, though this is a rare occasion on which I don’t wholeheartedly agree with him.

He notes:

Most [of] the profound and important changes we need to see in public services, we describe as ‘culture changes’… What do we mean by ‘culture change’? Generally, it’s code for a change we don’t think will happen and that we don’t think is our fault when it doesn’t.

Though I can see the point, I don’t think it is right.

Before looking at Alex’s central points and so exploring why I don’t think the above is  right, let’s briefly try to answer the following: “What is culture?”

There are many ways or frameworks for defining or understanding culture. McKinsey & Co famously defined it as

How we do things around here.

Schein expands (summarised in The Art of Change Making (pdf), p.131):

Culture is the way that an organisation survives. It is a way of being, believing and feeling that gives consistency and stability. It gives a way of surviving internal and external threat and disruption. It is how a place makes sense of the world. It is how it does things and how it chooses to be seen.

What this gives rise to are three levels of culture: tacit (what is assumed), espoused (what is spoken of) and observable (what is done in practice):

Culture-3 types
Schein’s three types of culture

How then, does culture – the way an organisation or system does things, survives and makes sense of the world – manifest itself? One of the more common ways of seeing this is through the Cultural Web (see pp.134-137 of The Art of Change Making). This sees culture as the result of the wonderfully Kafkaesque

Paradigm.

The paradigm is

the core beliefs of [an] organisation about themselves. The paradigm and the organisation’s behaviours, actions and thoughts are interlinked, they are a complex web and are inseparable. Every thought, behaviour and action feeds into the paradigm and the paradigm in turn influences every thought and action.

There are then thought to be six cultural influences that inform this paradigm and which are themselves informed by the paradigm (all of which exist at each of the three levels noted by Schein: tacit, espoused, observable).

Culture-web
The Cultural Web

With these common definitions of culture (and so culture change) in place, we can therefore explore the two central points of Alex’s post.

Just so you can see where I’m going with this, I’ll say now: we’ll see that culture change is precisely the sort of change Alex is rightly looking for.

The first main point in Alex’s post is this:

[I]n reality culture is always, always trumped by the hard levers and incentives in any system.

I think there is a grain of truth in this, but I think it underplays two issues.

The first is that hard levers and incentives themselves are part of the culture. In the Cultural Web they are examples of “Control Systems”, which

are the ways that an organisation controls how things are done, from things such as quality control and financial control, through to reward and punishment… People will behave in ways that they think will please the control system.

That is, what the organisation or system values is what leads to the creation of hard levers or incentives in the first place.

The second issue is that in any complex system the “hard” and the “soft” interact with each other in complex and possibly unknowable ways. (This is true even if you don’t think hard levers and incentives are part of the culture.) What this means is that for successful change to happen we should have both changes to the law, policy and financial flows that govern how systems are structured (the “hard”) and to the culture that governs how/why they work (“soft”).

The second main point in Alex’s post is about power:

Power on the other hand, is not elusive, and rarely dispersed… So next time someone in power suggests a culture change is needed, perhaps the appropriate question is, “[H]ow are you going to give your power to someone else, to start that happening?”

This point and related question about power are exactly right. From the definition of culture, though, we can see that power and power structures are part of the culture of an organisation or system. Or put another way: for power to be moved from one person to another is exactly to require a culture change.

It’s rare for me to disagree with Alex but I hope this post has explained why, on this occasion, I do. To summarise: if people use the phrase “culture change” as code for things they don’t think will happen, I’d suggest they probably don’t understand definitions of culture (at either a system or organisation level), how it manifests itself, and so what culture change might actually entail.

Times when the quiet carriage doesn’t, apparently, need to be quiet

quiet carriage
One of Queensland Rail’s cartoons as part of their train etiquette campaign
  • If the train is stationary at its departure station
  • Up to 5 minutes after the train has left its departure station
  • Up to 3 minutes before the train arrives at a station
  • Whilst the train is stopped at a station
  • Up to 3 minutes after the train leaves a station
  • Up to 10 minutes before the train arrives at its final destination
  • Any time at all (if you’re an ignoramus)

As I’ve written in detail before, we should get rid of quiet carriages. It’s the expectation that kills you.

Another cross-party commission on health and social care?

Andy Cowper is most probably right that there won’t be another cross-party commission on health and social care:

A cross-party funding commission on health and social care might get traction if funding issues represented an imminent and significant political challenge to the Government.

Thanks to The Fixed Term Parliaments Act and the tacit, uncivil war within the Labour Party, this does not seem likely.

Andy also makes another vital point: the Treasury doesn’t think there is an NHS financial crisis, let alone one that can be fixed by investing more in social care.

(As an aside, can someone explain to me why ex-Ministers seem to be more proactive in a policy area than they were when actually Minister for the relevant portfolio? This, of course, is a rhetorical question, but doesn’t make the situation any less frustrating.)

 

We need to talk about outcomes

Someone to love, somewhere to live, somewhere to work and something to hope for

— Norman Kirk, Prime Minister of New Zealand (1972-4)

In our relatively short time on this planet, people want different things. Norman Kirk set out what he thought people wanted from life. Others might add having children (or not) or earning as much money as they can (or not) etc., whilst others might focus on the process of living a good life: being happy, feeling valued etc.

Somewhere there is probably a list of the top 5 things people want from life.

These sorts of things, though, are a long way away from what outcomes in public services tend to reflect.

Take a look at the NHS Outcomes Framework or the Adult Social Care Outcomes Framework, for example (you could pick any public services outcomes framework you like and the argument would be the same). There are some good outcomes in these which begin to get at what could make for a good life: “social care-related quality of life“; “service users with as much social contact as they would like“. There are also plenty of stinkers: “number of patient safety incidents” (pdf); “hip fracture: incidence” (pdf).

 

Growing Tree Sequence
Image via SiklosKert

Despite the talk of outcomes in public services, we seem to have lost sight of the things people want from their lives and so how public services can enable people to achieve them.

Instead, public services focus on areas pretty narrowly defined by what is in their remit – areas that at their best are secondary to what people most often say they want from their life as a whole – love, home, work, hope.

It’s in this gap between what public services seem to think they are there for and what people want from their lives that I suspect we find much of our trouble. If a professional doesn’t see how the interaction they have with a person can help achieve what the person wants in their life, and also isn’t required to think beyond what the service they work for requires them to concentrate on, then that public service is flawed.

I wouldn’t want you to misinterpret me: if we did away with “outcomes”, relied only on inputs and outputs and kept our fingers crossed that these sum to a difference in people’s lives, then we won’t get anywhere either.

But part of me – the hopeful part, you could say – wants to see love, home, work, hope etc. at the very top of what it is public services are there to enable. All the other “outcomes” could  remain, but we’d see them for what they are: as the means to the greater ends that public services should be there for.